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MILD PAIN Pain Scale Rating 1/5 (0-5 Scale) or 1-3/10 (0-10 Scale) Complete Pain Assessment. Establish probable cause of pain when possible. Determine goal for pain relief with patient and acceptable time frame for when relief will occur. Always combine pharmacological interventions with non-pharmacological interventions. ANALGESICS SHOULD NOT BE HELD UNTIL CAUSE OF PAIN IS DETERMINED Initiate Non-Pharmacological Intervention *Partial Relief / No Relief: Pain Goal Not Met Relief: Pain Goal Met EXAMPLES OF ANALGESIC CHOICES acetaminophen ibuprofen celecoxib (Celebrex) refexocib (Vioxx) 650 mg q 4 hrs po or pr 200 mg 2-3 tabs q4hrs po 100 mg po bid 12.5-25 mg po qd MDD 4000mg MDD 3200 mg MDD 400mg MDD 50mg Continue Non-Pharmacological Interventions *Partial Relief / No Relief: Pain Goal Not Met REASSESS Review initial pain assessment for changes Anaglesics given as ordered Need to give before activities? Need for upward titration Is time interval appropriate? Need for adjuvant meds? *Partial Relief / No relief: Relief: Pain Goal Met Pain Goal Not Met *Consult physician. Develop plan for ongoing communication with physician until patient’s pain goal is met. Consider initiation of Moderate Pain Algorithm MDD = Maximum Daily dose ©MCW Research Foundation 2000 Continue interventions as needed Reassess at regular intervals Titrate as needed Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin MODERATE PAIN Pain Scale Rating 2-3/5 (0-5 Scale) or 4-6/10 (0-10 Scale) Complete Pain Assessment. Establish probable cause of pain when possible. Determine goal for pain relief with patient and acceptable time frame for when relief will occur. Always combine pharmacological interventions with non-pharmacological interventions. ANALGESICS SHOULD NOT BE HELD UNTIL CAUSE OF PAIN IS DETERMINED. Initiate Non-Pharmacological Interventions Examples of Analgesic Choices Tylenol # 2,3,4 (300mg acetaminophen/ 15mg (#2), 30mg (#3), 60mg (#4) mg codeine Ultram (tramadol) 50 mg Lortab 2.5/500 (2.5mg hydrocodone/500 mg acetaminophen) Roxicet (5mg oxycodone/325 mg. acetaminophen) Percocet 2.5/325, 5/325, 7.5/500 mg of oxycodone/acetaminophen Vicodin (5mg hydorcodone/500 acetaminophen) Vicodin ES (7.5 hydrocodone/750 mg acetaminophen) Lortab 7.5/500 (7.5mg hdyrocodone/500 mg acetaminophen) Vicoprofen 7.5/200 (7.5 hydrocodone/200 ibuprofen) NOTE: Maximum Daily Dose (MDD) of acetaminophen is 4000 mgs 1-2 tabs po 1-2 tabs po 1-2 tabs po 1-2 tabs po 1-2 tabs po 1-2 tabs po 1-2 tabs po 1-2 tabs po 1-2 tabs po q 4hrs q 6hrs q 4hrs q 4hrs q 4hrs q 4hrs q 4hrs q 4hrs q 4hrs Continue Non-Pharmacological Interventions *Partial Relief / No relief: Pain Goal Not Met REASSESS Review initial pain assessment for changes Analgesics given as ordered? Need to give before activities? Need for upward titration? Is time interval appropriate? Need for adjuvant meds? *Partial Relief / No Relief : Pain Goal Not Met *Consult physician. Develop plan for ongoing communication with physician until patient’s pain goal is met. Consider initiation of Severe Pain Algorithm © MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin. Relief: Pain Goal Met Continue interventions as above. Reassess at regular intervals. Titrate as needed. If pain is constant, convert to long acting drug at equianalgesic dose. (See Reference Information) SEVERE PAIN Pain Scale rating 4-5/5 (0-5 Scale) or 7-10/10 (0-10 Scale) Complete Pain Assessment. Establish probable cause of pain when possible. Determine goal for pain relief with patient and acceptable time frame for when relief will occur. Always combine pharmacological interventions with non-pharmacological interventions. ANALGESICS SHOULD NOT BE HELD UNTIL CAUSE OF PAIN IS DETERMINED. Initiate Non-Pharmacological Interventions Examples of Analgesic Choices Immediate Release, Short Acting Drugs (lowest dose available is listed) Note: There is no ceiling dose or maximum daily dose for these drugs morphine sulfate Tabs 10 mg q 2-4hr po or sl Elixir 20mg/ml or 2mg/ml q 2-4 hrs po or sl Suppository 10 mg q 2-4 hrs pr Parenteral 1-2mg q 15-30 min SC or IV oxycodone Tabs 5mg q 2-4 hrs po Elixir 5mg/ml or 20mg/ml q 2-4 hrs po hydromorphone (Dilaudid) Suppository 3mg q 4 hrs pr NOTE: Dilaudid 3mg suppository is equianalgesic to morphine sulfate 15 mg po or pr *Partial Relief / No Relief : Pain Goal Not Met Continue Non-Pharmacologic Interventions REASSESS Review initial pain assessment for changes Analgesics given as ordered Need for adjuvant drugs? Need for change to different opioid Need to give before activities? Need to change route of administration Is time interval appropriate? Need for upward titration Relief: Pain Goal Met *Partial Relief / No Relief. Pain Goal Not Met. Consult with physician. Develop plan for ongoing communication with physician until patient’s pain goal is met. ©MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin. Reassess at regular intervals. Titrate as necessary to maintain pain control. If pain is constant convert to long acting drugs, at equianalgesic dose. (See Reference Information) REFERENCE INFORMATION Opioid Equivalency Table Equianalgesic doses are approximate. Individual patient response must be observed. Caution: The doses listed ARE NOT recommended starting doses Short Acting Drugs Dose (mg) Parenteral morphine (MS soluble, 10 MSIR) 1,2,3 hydromorphone (Dilaudid) 1,2,3 1.5 oxycodone 4 hydrocodone 5 1 2 3 4 5 (mg) Oral 30 Duration (hour) 2-4 7.5 30 2-4 2-4 30 2-4 Available as a liquid Available as a suppository May be used as an IV or subcutaneous infusion Percocet contains varying strengths of oxycodone and acetaminophen per tablet. (2.5/325, 5/325,7.5/500) Read label carefully. Available only in combination with acetaminophen, ASA, or NSAID in tablet form; dosages range from 2.5-10.0 mg/tablet. ADJUVANT ANALGESICS Anticonvulsants Gabapentin (Neurontin) po Clonazepam (Klonopin) po Carbamazepine (Tegretol) po Antidepressants Desipramine (Norpramin)po Corticosteroids Dexamethasone (Decadron) po Prednisone 40-80 po Long Acting Drug Oramorph SR() MS Contin() Kadian() Oxycontin(,) Duragesic () REFERENCE TABLE Strength available 15, 30, 60, 100 mg 15, 30, 60, 100, 200mg 20, 50, 100 mg 10, 20, 40, 80, 160 mg 25,50,75,100 mcg Duration/Hr 8 - 12 8 - 12 12 - 24 8 - 12 48 - 72 1. Must be given as intact pills, cannot be crushed or used in G or J tubes 2. Capsule may be opened and sprinkled in food. 3. Consult package insert for conversion ratios for short acting to long acting opioids. 4. 24 hour po morphine dose 2=mcg/hr for the transdermal fentanyl patch (Duragesic) Note: Breakthrough analgesic medication should always be ordered along with long acting analgesic drugs. The suggested dose is 10 to 15% of the 24 hour dose and ordered q 1-2 hrs prn. STARTING DOSE 100mg q 8 hrs 0.5 mg q 8 hrs 100 mg BID 10 mg QHS 2-8 mg BID 40-80 mg daily © MCW Research Foundation 2000 Permission granted to modify or adopt provided written credit is given to the Medical College of Wisconsin.